Inside Health

The Patients in the Hallways

By DAVID HOLMBERG

Published: June 10, 2007

ON some chaotic days and nights, Dr. Peter Viccellio's system to control boarding -- the hospital practice of treating patients in the hallways of overcrowded emergency departments -- is still put to the test at Stony Brook University Hospital.

A delay in care or glitch connected to boarding can have extreme consequences for patients. ''Do they drop dead in front of you?'' Dr. Viccellio asked recently at the hospital, where he is vice chairman of emergency medicine and has practiced since 1988. ''No. But has their life permanently changed for the worse? Yes.''

Dr. Viccellio said boarding had been ''sharply reduced'' since 2001, after he began new procedures for dealing with emergency patients when the hospital is at or beyond capacity, but it is still a sporadic reality. And other doctors from the New York City area, New Jersey and Connecticut said they perceived boarding -- of patients receiving treatment in the emergency department or waiting for an inpatient bed -- as a primary symptom of overcrowding in American hospitals.

Dr. Michael L. Carius, chairman of the emergency department at Norwalk Hospital in Connecticut, summed up the concern for emergency department doctors who must resort to boarding because of overcrowding. ''Our biggest fear,'' he said, ''is the patient we haven't seen.''

More than half the doctors from New York State, New Jersey and Connecticut who responded to a survey conducted in April by the American College of Emergency Physicians said that boarding had increased significantly in recent years.

Doctors attribute it to emergency department and hospital overcrowding. The Institute of Medicine, a nonprofit group that advises on medicine and health, said in a recent report that emergency department visits grew by 26 percent from 1993 to 2003 while the number of emergency departments and hospital beds was declining.

The consequences of overcrowding can be fatal, doctors said. A total of 150 emergency department doctors in New York, Connecticut and New Jersey said that patients in their hospitals had died as a result of boarding, according to the survey by the American College of Emergency Physicians, a 25,000-member group that is pushing legislation in Congress to fight hospital overcrowding. The survey specified no time frame.

The group sent a 10-question survey about boarding to its 2,821 members in New York State, New Jersey and Connecticut. In New York, 28.2 percent of those responding said they ''personally had experience of a patient dying as a result of boarding.''

In Connecticut, 16.2 percent of the doctors responding said they had had a patient die as a result of boarding, and in New Jersey 11.9 percent of the doctors said they had.

The doctors requested anonymity and were reluctant to provide details about cases because of possible lawsuits and other repercussions.

''The fact that you have doctors in all three states reporting deaths from boarding indicates that it is a real problem,'' said Julie Lloyd, a spokeswoman for the American College of Emergency Physicians in Washington (the organization is headquartered in Dallas).

Ms. Lloyd said the survey was the first by her group, or any other she knew of, to try to assess the number of deaths resulting from boarding. She said in an e-mail message that a key point in legislation before Congress ''is to collect boarding statistics, which heretofore have remained the province of the hospitals.''

A spokeswoman for the New Jersey Hospital Association, Kerry McKean Kelly, said she had ''not heard of any deaths'' resulting from boarding in New Jersey, but ''we don't think there's any disagreement'' that boarding and overcrowding are serious problems, and ''everyone shares responsibility on this issue.''

Jennifer Barrows, a spokeswoman for the Connecticut Hospital Association, said that although she had not heard of deaths caused by boarding, it is a ''severe problem for patients every day.'' She called the boarding of mental health patients a particularly serious issue in Connecticut.

Dr. Viccellio said 3,000 boarders had gone through the Stony Brook hospital under his revised system and estimated that hundreds of hospitals nationwide had begun using it.

The premise of his regulations: When an emergency department is seriously overcrowded and patients are boarded in the hallways, their care and that of any new patient can be jeopardized. So emergency department boarders are moved to the hallways of inpatient units -- 10 at Stony Brook -- where they can be treated in a unit designed for their condition until a room becomes available. Those units are also less crowded.

Dr. Viccellio described his plan as a ''decompression valve'' that relieves the pressure on emergency departments and results in ''better care for all patients, more timely treatment and fewer errors.''

He created the system after years of frustration with boarding problems at Stony Brook -- a frustration felt throughout the country, said other doctors who were interviewed.

Dr. Viccellio's department often boarded up to 15 to 20 patients before his protocol. Now, he said, when boarding occurs it usually involves seven or eight patients. The most common complaint for boarded patients is chest pains, he said.

Only two patients can be assigned to another unit, he said, ''so you might have a situation where five nurses are treating 32 patients instead of 30'' in a given inpatient unit. That is far preferable, he said, to the emergency department bearing the burden of overcrowding by itself.

Some hospitals have expressed concern about the impact of Dr. Viccellio's system on nursing staffs, but spokeswomen for the New York State Nurses Association and the Emergency Nurses Association, in Des Plaines, Ill., said that in general their groups support efforts to relieve boarding.

''I think that studies have shown that whenever you put a patient on a general floor, they get beds a lot quicker than when they're out of sight in an emergency department,'' said Donna Mason, president of the Emergency Nurses Association.

Photos: DELAYS Above, Dr. Michael L. Carius, head of Norwalk Hospital's emergency department, top. Left, Dr. Peter Viccellio, vice chairman of emergency medicine at Stony Brook University Hospital. (Photographs by Thomas MacDonald for The New York Times); (Photo by Ed Betz for The New York Times)